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R 5132 (2) PERMIT R_ 513 2 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR • 160 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS y /� /�� \J'� 16)W —9 C,/ I; . RESIDENTIAL ' COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAME 110MAS ScANNEL..�- YES ❑ Ifyes s Imblyi required. NO Class roof assembly Is required. NO ❑ Initial I.C.B.O.# ADDRESS 1010S /`AZ PL• EXISTING ROOF COVERING PHONE 26S -2-719 NUMBER OF EXISTING COVERINGS CONTRACTOR'S //�� ,• Y65l A15$AN C6 a0z5F- Ir-)G Gp zl/yl r TO BE REMOVED "�TO BE RETAINED NAME ADDRESS2Z- 1 Z LI �L N AU6. TYPE OF ROOF COVERING CITY&ZIP +016 44q -9)(6C4 + EXISTING PHONE- BUILT-UP ROOF ❑ LICENSE NUMBER GrJ63ro ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 6(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect' WOOD WOOD SHINGLESxe-13 ❑ License Claes yr 1 LIc.Number 551 -73(.Dale �5 v Contractor �AIS5ArJGE QtFIfJ6 OTHER(SPECIFY)OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he Is licensed pursuer;to the provisions of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the • Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.6 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7004,Business and Profes- sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sale.If,however,the building or Improvement D Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) xp� rIC not build or Improve for purpose of sale.), Al ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct Q the project(Sec.7044,Business and Professions Cotle:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. 3'�- •' apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(e)licensed pursuant to the Contracture License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION'DATE VALUATION PER IT FE I hereby affirm under penalty of perjury one of the following declaration: A I]I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, /— '[ Buildin permitprovidedIs Is for by Section 3700 of the Labor Code,for the performance of the work for which this ;, � ��Lb I zs I / g permit la Issued. I ; rD t ✓r6 SeismIC I have and will the performance Workers Compensation which this as permit Is by Section Worker's of V V / the Leber Code,for the pedormand of the work for which tole permit le leeuetl.My Worker's i/ i Cr Compensation Insurance carrier end Policy number are: p V Total Carrier SPATE r00fl Policy No. PERMITAUTHORIZA N DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.] (This section need not be completed If the permit Is for one hundred dollars($100)or less.) f cenly that In the performance of the work for which this permit Is issued,I shell not employ any person In any manner so as to become euble to the W rkers'Compensation Laws of Cali. All roofs shall a inspected pr r any to ng me erial being fornix. installed. It a roof is installs without first obtainin an q 1 s Date �� rL Applicant �. ��'�„d{ inspection,I agree to remove all new materials for inspection. ecome subject to the WE TO orkers'Comparke tion provisioPLICANT: If,after making ns of the flLabor Code,cate of you mustuforthwith acomply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. sour, a regulations. I certify that I have read this application and stele that the above Information Is correct.)agree to comply with all city and county ordinances and state laws relating to building construction,and All of coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In.spectiAz-�� //— ud'Wonpurpoeee. ly" 4 J�y (We)agree m save,penesIndemnityw and keep harmless the City ai st Cupertino Ci against liabilities, Yss'•1/�7/ Z of I7manta,costa and expenses wM1ICM1 may In any way accrue against 9altl City In consequence • of thegranting othis permit. SIGNATURE OF APPLICANT DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY